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Localized nodular synovitis: A rare cause of ulnar nerve compression in Guyon's canal
Localized nodular synovitis: A rare cause of ulnar nerve compression in Guyon’s canal A rare case of ulnar nerve entrapment
at the wrist by a nodule of localized nodular synovitis is
presented. The literature is reviewed with particular reference to the causes of ulnar tunnel syndrome, the uncertainty over the origin of this type of tumor, and its tendency to recur after incomplete excision. (J HAND SURC 1992;17A:663-4.)
P. G. Budny,
FRCS,
Buckinghamshire,
P. J. Regan,
FRCS,
L
ocalized nodular synovitis (giant cell tumour of tendon sheath or pigmented villonodular synovitis) is a common hand tumor but a rare cause of ulnar nerve compression at the wrist. Many different names have been given to this tumor, reflecting a lack of consensus regarding its tissue of origin and pathologic behavior. In the case that follows, its presence within Guyon’s canal suggests that it arose from epineurium or from the synovium of an intercarpal joint. Case report A 50-year-old woman, employed as a quality control auditor, had a 2-year history of a painful lump in the palm of her nondominant left hand. She complained of weakness of hand function and marked paresthesia, with some numbness of the ulnar one and one half digits. She denied past trauma to the hand. Examination revealed a firm, tender swelling at the base of the hypothenar eminence. The clawed posture of the ring and small fingers with intrinsic weakness suggested an ulnar motor paresis. Sensory testing and Tinel’s test showed no abnormality in spite of her symptoms. Exploration of the ulnar nerve at the wrist defined a circumscribed, yellow-gray mass 7 mm in diameter arising from the radial aspect of the canal and projecting within it to com-
From the Department of Plastic Surgery, Stoke Mandeville Hospital. Buckinghamshire.
England.
Received for publication March I. 1991.
Nov. 8. 1990; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: P. G. Budny. BSc, FRCS, Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury. Buckinghamshire. England. 3/l/30632
and A. H. N. Roberts,
FRCS,
England
press the nerve proximal to its division (Fig. 1). The tumor was carefully excised in its entirety, and 1 month postoperatively the patient was free of symptoms with full recovery of hand function. The histologic diagnosis was localized nodular synovitis. One year later there had been no recurrence of the tumor. Discussion
Ulnar nerve compression syndromes at the wrist and their historical background have been thoroughly investigated and reviewed.le3 The ulnar tunnel syndrome’ is well defined in reference texts4. ’ with the causes being reported as acute and chronic trauma, anomalous muscles, fascial and tendinous bands, and a variety of space-occupying lesions within Guyon’s canal. The localized form of pigmented villonodular synovitis presented here is only the second example of an otherwise common hand tumor producing this symptom complex. A review of the literature shows ganglia to be the most common swellings producing the syndrome. ‘. 6 Isolated reports of lipomas7-9 and neurilemomas’“~ ’ ’ are referred to in current texts,5 but Hayes’ case” of giant cell tumor of tendon sheath is noted only by Eversmann. I3 This lesion has been given many names, including pigmented villonodular synovitis, pigmented nodular tenosynovitis, giant cell tumor of tendon sheath, fibrous xanthoma of synovium, and benign synovioma. Hayes” used the synonym$brous histiocytoma, a term we have not found in common use for this condition. The lesion is of uncertain origin. ListeiJ states that it is always found in the presence of synovial tissue, and he also maintains that Guyon’s canal contains no synovium. Mason,’ in a review of hand tumors, suggests that it may develop as a bone tumor from the bones of the wrist or from the fibrous tissue of tendon sheaths, fascial layers, and ligaments, periosteum. or perineural tissue. In this case involving Guyon’s canal it must have orig-
THE
JOURNAL
OF HAND
SURGERY
663
664
The Journal of HAND SURGERY
Budny et al.
Fig. 1. Roof of Guyon’s tunnel opened demonstrating compressing
nodule of localized nodular synovitis (arrow)
ulnar nerve proximal to its division
inated from epineurium or the synovium of an intercarpal joint. The characteristic gray-yellow-brown mottled tumor is said to surround normal structures rather than displacing them.4 This case demonstrates that within the confines of the ulnar tunnel such a lesion may produce distortion and compression of a progressive nature. There is agreement that no case of metastasis has been carefully documented but that recurrence is common if excision is incomplete,14 as in the patient described by Hayes. I2 REFERENCES 1. DuPont C, Clouthier GE, Prevost Y, Dion MA. Ulnar tunnel syndrome at the wrist. J Bone Joint Surg 1965;47A:757-61. 2. Shea D, McClean EJ. Ulnar nerve compression syndromes at and below the wrist. J Bone Joint Surg 1969;51A:1095-103. 3. Kleinert HE, Hayes JE. The ulnar tunnel syndrome. Plast Reconstr Surg 1971;47:21-4. and indications. 2nd ed. 4. Lister G. The hand-diagnosis Edinburgh: Churchill Livingstone, 1984:202, 300-l. 5. Coyle MP. Nerve entrapment syndromes. In: Dee R, Mango F, Hurst LC, eds. Principles of orthopaedic practice. New York: McGraw-Hill, 1988;680-1.
6. Seddon HJ. Carpal ganglion as a cause of paralysis of the deep branch of the ulnar nerve. J Bone Joint Surg 1952;34B:386-90. 7. Mason ML. Tumours of the hand. Surg Gynecol Obstet 1937;64:129-48. 8. McFarland GB, Hoffer MM. Paralysis of the intrinsic muscles of the hand secondary to lipoma in Guyon’s tunnel. J Bone Joint Surg 1971;53A:375-6. ulnar neuropathy at 9. Zahrawi F. Acute compression Guyon’s canal resulting from lipoma. J HAND SURG 1984;9A:238-40. 10. Jenkins SA. Solitary tumours of peripheral nerve trunks. J Bone Joint Surg 1952;34B:401-11. 11. White NB .Neurilemomas of the extremities. J Bone Joint Surg 1967;49A:1605-10. 12. Hayes CW. Ulnar tunnel syndrome from giant cell tumour of tendon sheath: a case report. J HAND SURG 1978;3A:187-8. 13. Eversmann W.~ Entrapment and compression neuropathies. In: Green DP, ed. Operative hand surgery. 2nd ed. Edinburgh: Churchill Livingstone, 1988:1452-3. 14. Catto ME. Locomotor system. In: Anderson JR, ed. Muir’s textbook of pathology. 11th ed. London: Edward Arnold, 1980:926-7.
at the wrist by a nodule of localized nodular synovitis is
presented. The literature is reviewed with particular reference to the causes of ulnar tunnel syndrome, the uncertainty over the origin of this type of tumor, and its tendency to recur after incomplete excision. (J HAND SURC 1992;17A:663-4.)
P. G. Budny,
FRCS,
Buckinghamshire,
P. J. Regan,
FRCS,
L
ocalized nodular synovitis (giant cell tumour of tendon sheath or pigmented villonodular synovitis) is a common hand tumor but a rare cause of ulnar nerve compression at the wrist. Many different names have been given to this tumor, reflecting a lack of consensus regarding its tissue of origin and pathologic behavior. In the case that follows, its presence within Guyon’s canal suggests that it arose from epineurium or from the synovium of an intercarpal joint. Case report A 50-year-old woman, employed as a quality control auditor, had a 2-year history of a painful lump in the palm of her nondominant left hand. She complained of weakness of hand function and marked paresthesia, with some numbness of the ulnar one and one half digits. She denied past trauma to the hand. Examination revealed a firm, tender swelling at the base of the hypothenar eminence. The clawed posture of the ring and small fingers with intrinsic weakness suggested an ulnar motor paresis. Sensory testing and Tinel’s test showed no abnormality in spite of her symptoms. Exploration of the ulnar nerve at the wrist defined a circumscribed, yellow-gray mass 7 mm in diameter arising from the radial aspect of the canal and projecting within it to com-
From the Department of Plastic Surgery, Stoke Mandeville Hospital. Buckinghamshire.
England.
Received for publication March I. 1991.
Nov. 8. 1990; accepted
in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: P. G. Budny. BSc, FRCS, Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury. Buckinghamshire. England. 3/l/30632
and A. H. N. Roberts,
FRCS,
England
press the nerve proximal to its division (Fig. 1). The tumor was carefully excised in its entirety, and 1 month postoperatively the patient was free of symptoms with full recovery of hand function. The histologic diagnosis was localized nodular synovitis. One year later there had been no recurrence of the tumor. Discussion
Ulnar nerve compression syndromes at the wrist and their historical background have been thoroughly investigated and reviewed.le3 The ulnar tunnel syndrome’ is well defined in reference texts4. ’ with the causes being reported as acute and chronic trauma, anomalous muscles, fascial and tendinous bands, and a variety of space-occupying lesions within Guyon’s canal. The localized form of pigmented villonodular synovitis presented here is only the second example of an otherwise common hand tumor producing this symptom complex. A review of the literature shows ganglia to be the most common swellings producing the syndrome. ‘. 6 Isolated reports of lipomas7-9 and neurilemomas’“~ ’ ’ are referred to in current texts,5 but Hayes’ case” of giant cell tumor of tendon sheath is noted only by Eversmann. I3 This lesion has been given many names, including pigmented villonodular synovitis, pigmented nodular tenosynovitis, giant cell tumor of tendon sheath, fibrous xanthoma of synovium, and benign synovioma. Hayes” used the synonym$brous histiocytoma, a term we have not found in common use for this condition. The lesion is of uncertain origin. ListeiJ states that it is always found in the presence of synovial tissue, and he also maintains that Guyon’s canal contains no synovium. Mason,’ in a review of hand tumors, suggests that it may develop as a bone tumor from the bones of the wrist or from the fibrous tissue of tendon sheaths, fascial layers, and ligaments, periosteum. or perineural tissue. In this case involving Guyon’s canal it must have orig-
THE
JOURNAL
OF HAND
SURGERY
663
664
The Journal of HAND SURGERY
Budny et al.
Fig. 1. Roof of Guyon’s tunnel opened demonstrating compressing
nodule of localized nodular synovitis (arrow)
ulnar nerve proximal to its division
inated from epineurium or the synovium of an intercarpal joint. The characteristic gray-yellow-brown mottled tumor is said to surround normal structures rather than displacing them.4 This case demonstrates that within the confines of the ulnar tunnel such a lesion may produce distortion and compression of a progressive nature. There is agreement that no case of metastasis has been carefully documented but that recurrence is common if excision is incomplete,14 as in the patient described by Hayes. I2 REFERENCES 1. DuPont C, Clouthier GE, Prevost Y, Dion MA. Ulnar tunnel syndrome at the wrist. J Bone Joint Surg 1965;47A:757-61. 2. Shea D, McClean EJ. Ulnar nerve compression syndromes at and below the wrist. J Bone Joint Surg 1969;51A:1095-103. 3. Kleinert HE, Hayes JE. The ulnar tunnel syndrome. Plast Reconstr Surg 1971;47:21-4. and indications. 2nd ed. 4. Lister G. The hand-diagnosis Edinburgh: Churchill Livingstone, 1984:202, 300-l. 5. Coyle MP. Nerve entrapment syndromes. In: Dee R, Mango F, Hurst LC, eds. Principles of orthopaedic practice. New York: McGraw-Hill, 1988;680-1.
6. Seddon HJ. Carpal ganglion as a cause of paralysis of the deep branch of the ulnar nerve. J Bone Joint Surg 1952;34B:386-90. 7. Mason ML. Tumours of the hand. Surg Gynecol Obstet 1937;64:129-48. 8. McFarland GB, Hoffer MM. Paralysis of the intrinsic muscles of the hand secondary to lipoma in Guyon’s tunnel. J Bone Joint Surg 1971;53A:375-6. ulnar neuropathy at 9. Zahrawi F. Acute compression Guyon’s canal resulting from lipoma. J HAND SURG 1984;9A:238-40. 10. Jenkins SA. Solitary tumours of peripheral nerve trunks. J Bone Joint Surg 1952;34B:401-11. 11. White NB .Neurilemomas of the extremities. J Bone Joint Surg 1967;49A:1605-10. 12. Hayes CW. Ulnar tunnel syndrome from giant cell tumour of tendon sheath: a case report. J HAND SURG 1978;3A:187-8. 13. Eversmann W.~ Entrapment and compression neuropathies. In: Green DP, ed. Operative hand surgery. 2nd ed. Edinburgh: Churchill Livingstone, 1988:1452-3. 14. Catto ME. Locomotor system. In: Anderson JR, ed. Muir’s textbook of pathology. 11th ed. London: Edward Arnold, 1980:926-7.